Family, Social, Cultural, and Religious Influences on Child Health Promotion

Chapter 27

Family, Social, Cultural, and Religious Influences on Child Health Promotion

Marilyn J. Hockenberry

Definition of Family

The term family has been defined in many different ways according to the individual’s own frame of reference, values, or discipline. There is no universal definition of family; a family is what an individual considers it to be. Biology describes the family as fulfilling the biologic function of perpetuation of the species. Psychology emphasizes the interpersonal aspects of the family and its responsibility for personality development. Economics views the family as a productive unit providing for material needs. Sociology depicts the family as a social unit interacting with the larger society, creating the context within which cultural values and identity are formed. Others define family in terms of the relationships of the persons who make up the family unit. The most common type of relationships are consanguineous (blood relationships), affinal (marital relationships), and family of origin (family unit a person is born into).

Earlier definitions of family emphasized that family members were related by legal ties or genetic relationships and lived in the same household with specific roles. Later definitions have been broadened to reflect both structural and functional changes. A family can be defined as an institution in which individuals, related through biology or enduring commitments and representing similar or different generations and genders, participate in roles involving mutual socialization, nurturance, and emotional commitment (Coehlo, Kaakinen, Hanson, et al., 2009). Nursing care of infants and children is intimately involved with care of the child and the family. Family structure and dynamics can have an enduring influence on a child, affecting the child’s health and well-being. Consequently, nurses must be aware of the functions of the family, various types of family structures, and theories that provide a foundation for understanding the changes within a family and for directing family-oriented interventions.

Family Structure

The family structure, or family composition, consists of individuals, each with a socially recognized status and position, who interact with one another on a regular, recurring basis in socially sanctioned ways (Coehlo, Kaakinen, Hanson, et al., 2009) (Fig. 27-1). When members are gained or lost through events such as marriage, divorce, birth, death, abandonment, or incarceration, the family composition is altered and roles must be redefined or redistributed.

Traditionally, the family structure was either a nuclear or extended family. In recent years, family composition has assumed new configurations, with the single-parent family and blended family becoming prominent forms. The predominant structural pattern in any society depends on the mobility of families as they pursue economic goals and as relationships change. It is not uncommon for children to belong to several different family groups during their lifetime.

Nurses must be able to meet the needs of children from many diverse family structures and home situations. A family’s particular structure affects the direction of nursing care. The U.S. Census Bureau uses four definitions for families: the traditional nuclear family, the nuclear family, the blended family or household, and the extended family or household.

Family Strengths and Functioning Style

Family function refers to the interactions of family members, especially the quality of those relationships and interactions (Bomar, 2004). Researchers are interested in family characteristics that help families function effectively. Knowledge of these factors guides the nurse throughout the nursing process and helps the nurse to predict ways that families may cope and respond to a stressful event, to provide individualized support that builds on family strengths and unique functioning style, and to assist family members in obtaining resources.

Family strengths and unique functioning styles (Box 27-1) are significant resources that nurses can use to meet family needs. Building on qualities that make a family work well and strengthening family resources make the family unit even stronger. All families have strengths as well as vulnerabilities.

Box 27-1

Qualities of Strong Families

• A belief and sense of commitment toward promoting the well-being and growth of individual family members, as well as the family unit

• Appreciation for the small and large things that individual family members do well and encouragement to do better

• Concentrated effort to spend time and do things together, no matter how formal or informal the activity or event

• A sense of purpose that permeates the reasons and basis for “going on” in both bad and good times

• A sense of congruence among family members regarding the value and importance of assigning time and energy to meet needs

• The ability to communicate with one another in a way that emphasizes positive interactions

• A clear set of family rules, values, and beliefs that establishes expectations about acceptable and desired behavior

• A varied repertoire of coping strategies that promote positive functioning in dealing with both normative and nonnormative life events

• The ability to engage in problem-solving activities designed to evaluate options for meeting needs and procuring resources

• The ability to be positive and see the positive in almost all aspects of their lives, including the ability to see crisis and problems as an opportunity to learn and grow

• Flexibility and adaptability in the roles necessary to procure resources to meet needs

• A balance between the use of internal and external family resources for coping and adapting to life events and planning for the future

From Dunst C, Trivette C, Deal A: Enabling and empowering families: principles and guidelines for practice, Cambridge, MA, 1988, Brookline Books.

Family Roles and Relationships

Each individual has a position, or status, in the family structure and plays culturally and socially defined roles in interactions within the family. Each family also has its own traditions and values and sets its own standards for interaction within and outside the group. Each determines the experiences the children should have, those they are to be shielded from, and how each of these experiences meets the needs of family members. When family ties are strong, social control is highly effective and most members conform to their roles willingly and with commitment. Conflicts arise when people do not fulfill their roles in ways that meet other family members’ expectations, either because they are unaware of the expectations or because they choose not to meet them.

Parental Roles

In all family groups, the socially recognized status of father and mother exists with socially sanctioned roles that prescribe appropriate sexual behavior and childrearing responsibilities. The guides for behavior in these roles serve to control sexual conflict in society and provide for prolonged care of children. The degree to which parents are committed and the way they play their roles are influenced by a number of variables and by the parents’ unique socialization experience.

Parental role definitions have changed as a result of the changing economy and increased opportunities for women (Bomar, 2004). As the woman’s role has changed, the complementary role of the man has also changed. Many fathers are more active in childrearing and household tasks. As the redefinition of gender roles continues in American families, role conflicts may arise in many families because of a cultural lag of the persisting traditional role definitions.

Family Size and Configuration

Parenting practices differ between small and large families. Small families place more emphasis on the individual development of the children. Parenting is intensive rather than extensive, and there is constant pressure to measure up to family expectations. Children’s development and achievement are measured against those of other children in the neighborhood and social class. In small families, children have more democratic participation than in larger families. Adolescents in small families identify more strongly with their parents and rely more on them for advice. They have well-developed, autonomous inner controls as contrasted with adolescents from larger families, who rely more on adult authority.

Children in a large family are able to adjust to a variety of changes and crises. There is more emphasis on the group and less on the individual (Fig. 27-2). Cooperation is essential, often because of economic necessity. The large number of people sharing a limited amount of space requires a greater degree of organization, administration, and authoritarian control. A dominant family member (a parent or older child) wields control. The number of children reduces the intimate, one-to-one contact between the parent and any individual child. Consequently, children turn to each other for what they cannot get from their parents. The reduced parent-child contact encourages individual children to adopt specialized roles to gain recognition in the family.

Older siblings in large families often administer discipline. Siblings are usually attuned to what constitutes misbehavior. Sibling disapproval or ostracism is frequently a more meaningful disciplinary measure than parental interventions. In situations such as death or illness of a parent, an older sibling often assumes responsibility for the family at considerable personal sacrifice. Large families generate a sense of security in the children that is fostered by sibling support and cooperation. However, adolescents from a large family are more peer oriented than family oriented.

Special Parenting Situations

Parenting is a demanding task under ideal circumstances, but when parents and children face situations that deviate from “the norm,” the potential for family disruption is increased. Situations that are encountered frequently are divorce, single parenthood, blended families, adoption, and dual-career families. In addition, as cultural diversity increases in our communities, many immigrants are making the transition to parenthood and a new country, culture, and language simultaneously. Other situations that create unique parenting challenges are parental alcoholism, homelessness, and incarceration. Although these topics are not addressed here, the reader may wish to investigate them further.

Parenting the Adopted Child

Adoption establishes a legal relationship between a child and parents who are not related by birth but who have the same rights and obligations that exist between children and their biologic parents. In the past, the biologic mother alone made the decision to relinquish the rights to her child. In recent years, the courts have acknowledged the legal rights of the biologic father regarding this decision. Concerned child advocates have questioned whether decisions that honor the father’s rights are in the best interests of the child. As the child’s rights have become recognized, older children have successfully dissolved their legal bond with their biologic parents to pursue adoption by adults of their choice. Furthermore, there is a growing interest and demand within the gay and lesbian community to adopt.

Unlike biologic parents, who prepare for their child’s birth with prenatal classes and the support of friends and relatives, adoptive parents have fewer sources of support and preparation for the new addition to their family. Nurses can provide the information, support, and reassurance needed to reduce parental anxiety regarding the adoptive process and refer adoptive parents to state parental support groups. Such sources can be contacted through a state or county welfare office.

The sooner infants enter their adoptive home, the better the chances of parent-infant attachment. However, the more caregivers the infant had before adoption, the greater the risk for attachment problems. The infant must break the bond with the previous caregiver and form a new bond with the adoptive parents. Difficulties in forming an attachment depend on the amount of time he or she has spent with caregivers early in life as well as the number of caregivers (e.g., the birth mother, nurse, adoption agency personnel).

Siblings, adopted or biologic, who are old enough to understand should be included in decisions regarding the commitment to adopt, with reassurance that they are not being replaced. Ways that the siblings can interact with the adopted child should be stressed (Fig. 27-3).

Issues of Origin

The task of telling children that they are adopted can be a cause of deep concern and anxiety. There are no clear-cut guidelines for parents to follow in determining when and at what age children are ready for the information. Parents are naturally reluctant to present such potentially unsettling news. However, it is important that parents not withhold the adoption from the child, since it is an essential component of the child’s identity.

The timing arises naturally as parents become aware of the child’s readiness. Most authorities believe that children should be informed at an age young enough so that, as they grow older, they do not remember a time when they did not know they were adopted. The time is highly individual but must be right for both the parents and the child. It may be when children ask where babies come from, at which time children can also be told the facts of their adoption. If they are told in a way that conveys the idea that they were active participants in the selection process, they will be less likely to feel that they were abandoned victims in a helpless situation. For example, parents can tell children that their personal qualities drew the parents to them. It is wise for parents who have not previously discussed adoption to tell children that they are adopted before the children enter school, to avoid having them learn it from third parties. Complete honesty between parents and children strengthens the relationship.

Parents should anticipate behavior changes after the disclosure, especially in older children. Children who are struggling with the revelation that they are adopted may benefit from individual and family counseling. Children may use the fact of their adoption as a weapon to manipulate and threaten parents. Statements such as “My real mother would not treat me like this” or “You don’t love me as much because I’m adopted” hurt parents and increase their feelings of insecurity. Such statements may also cause parents to become over-permissive. Adopted children need the same undemanding love, combined with firm discipline and limit setting, as any other child.


Adolescence may be an especially trying time for parents of adopted children. The normal confrontations of adolescents and parents assume more painful aspects in adoptive families. Adolescents may use their adoption to defy parental authority or as a justification for aberrant behavior. As they attempt to master the task of identity formation, they may begin to have feelings of abandonment by their biologic parents. Gender differences in reacting to adoption may surface.

Adopted children fantasize about their biologic parents and may feel the need to discover their parents’ identity to define themselves and their own identity. It is important for parents to keep the lines of communication open and to reassure their child that they understand the need to search for their identity. In some states, birth certificates are made legally available to adopted children when they come of age. Parents should be honest with questioning adolescents and tell them of this possibility (the parents themselves are unable to obtain the birth certificate; it is the children’s responsibility if they desire it).

Cross-Racial and International Adoption

Adoption of children from racial backgrounds different from that of the family is commonplace. In addition to the problems faced by adopted children in general, children of a cross-racial adoption must deal with physical and sometimes cultural differences. It is advised that parents who adopt children with different ethnic background do everything to preserve the adopted children’s racial heritage.

Although the children are full-fledged members of an adopting family and citizens of the adopted country, if they have a strikingly different appearance from other family members or exhibit distinct racial or ethnic characteristics, challenges may be encountered outside the family. Bigotry may appear among relatives and friends. Strangers may make thoughtless comments and talk about the children as though they were not members of the family. It is vital that family members declare to others that this is their child and a cherished member of the family.

In international adoptions, the medical information the parents receive may be incomplete or sketchy; weight, height, and head circumference are often the only objective information present in the child’s medical record. Many internationally adopted children were born prematurely, and common health problems such as infant diarrhea and malnutrition delay growth and development. Some children have serious or multiple health problems that can be stressful for the parents.

Parenting and Divorce

Since the mid-1960s, a marked change in the stability of families has been reflected in increased rates of divorce, single parenthood, and remarriage. In 2008, the divorce rate for the United States was 3.4 per 1000 total population (Centers for Disease Control and Prevention [CDC], 2012). The divorce rate has changed little since 1987. In the decade before that, the rate increased yearly, with a peak in 1979. Although almost half of all divorcing couples are childless, it is estimated that more than 1 million children experience divorce each year.

The process of divorce begins with a period of marital conflict of varying length and intensity, followed by a separation, the actual legal divorce, and the reestablishment of different living arrangements. Because a function of parenthood is to provide for the security and emotional welfare of children, disruption of the family structure often engenders strong feelings of guilt in the divorcing parents.

During a divorce, parents’ coping abilities may be compromised. The parents may be preoccupied with their own feelings, needs, and life changes and be unavailable to support their children. Newly employed parents, usually mothers, are likely to leave children with new caregivers, in strange settings, or alone after school. The parent may also spend more time away from home, searching for or establishing new relationships. Sometimes, however, the adult feels frightened and alone and begins to depend on the child as a substitute for the absent parent. This dependence places an enormous burden on the child.

Common characteristics in the custodial household after separation and divorce include disorder, coercive types of control, inflammable tempers in both parents and children, reduced parental competence, a greater sense of parental helplessness, poorly enforced discipline, and diminished regularity in household routines. Noncustodial parents are seldom prepared for the role of visitor, may assume the role of recreational and “fun” parent, and may not have a residence suitable for children’s visits. They may also be concerned about maintaining the arrangement over the years to follow.

Impact of Divorce on Children

Parental divorce is an additional childhood adversity that contributes to poor mental health outcomes, especially when combined with child abuse. Parental psychopathology may be one possible mechanism to explain the relationships between child abuse, parental divorce, and psychiatric disorders and suicide attempts (Afifi, Boman, Fleisher, et al., 2009). Even when a divorce is amicable and open, children recall parental separation with the same emotions felt by victims of a natural disaster: loss, grief, and vulnerability to forces beyond their control. A recent study found that increasing one of children’s most important interpersonal resources—the quality of the mother-child relationship—improved children’s post-divorce adjustment (Velez, Wolchik, Tein, et al., 2011).

The impact of divorce on children depends on several factors, including the age and gender of the children, the outcome of the divorce, and the quality of the parent-child relationship and parental care during the years after the divorce. Family characteristics are more crucial to the child’s well-being than specific child characteristics such as age or gender. High levels of ongoing family conflict are related to problems of social development, emotional stability, and cognitive skills for the child.

Feelings of children toward divorce vary with age (Box 27-2). Previously, researchers believed that divorce had a greater impact on younger children, but recent observations indicate that divorce constitutes a major disruption for children of all ages. The feelings and behaviors of children may be different for various ages and gender, but all children suffer stress second only to the stress produced by the death of a parent. Although considerable research has looked at gender differences in children’s adjustments to divorce, the findings are not conclusive.

Box 27-2   Feelings and Behaviors of Children Related to Divorce

Some children feel a sense of shame and embarrassment concerning the family situation. Sometimes children see themselves as different, inferior, or unworthy of love, especially if they feel responsible for the family dissolution. Although the social stigma attached to divorce no longer produces the emotions it did in the past, such feelings may still exist in small towns or in some cultural groups and can reinforce children’s negative self-image. The lasting effects of divorce depend on the children’s and the parents’ adjustment to the transition from an intact family to a single-parent family and, often, to a reconstituted family.

Although most studies have concentrated on the negative effects of divorce on youngsters, some positive outcomes of divorce have been reported. A successful post-divorce family, either a single-parent or a reconstituted family, can improve the quality of life for both adults and children. If conflict is resolved, a better relationship with one or both parents may result, and some children may have less contact with a disturbed parent. Greater stability in the home setting and the removal of arguing parents can be a positive outcome for the child’s long-term well-being.

Telling the Children

Parents are understandably hesitant to tell children about their decision to divorce. Most parents neglect to discuss either the divorce or its inevitable changes with their preschool child. Without preparation, even children who remain in the family home are confused by the parental separation. Frequently, children are already experiencing vague, uneasy feelings that are more difficult to cope with than being told the truth about the situation.

If possible, the initial disclosure should include both parents and siblings, followed by individual discussions with each child. Sufficient time should be set aside for these discussions, and they should take place during a period of calm, not after an argument. Parents who physically hold or touch their children provide them with a feeling of warmth and reassurance. The discussions should include the reason for the divorce, if age-appropriate, and reassurance that the divorce is not the fault of the children.

Parents should not fear crying in front of the children, because their crying gives the children permission to cry also. Children need to ventilate their feelings. Children may feel guilt or a sense of failure or that they are being punished for misbehavior. They normally feel anger and resentment and should be allowed to communicate these feelings without punishment. They also have feelings of terror and abandonment. They need consistency and order in their lives. They want to know where they will live, who will take care of them, if they will be with their siblings, and if there will be enough money to live on. Children may also wonder what will happen on special days such as birthdays and holidays, whether both parents will come to school events, and whether they will still have the same friends. Children fear that if their parents stopped loving each other, they could stop loving them. Their need for love and reassurance is tremendous at this time.

Custody and Parenting Partnerships

In the past, when parents separated, the mother was given custody of the children with visitation agreements for the father. Now both parents and the courts are seeking alternatives. Current belief is that neither fathers nor mothers should be awarded custody automatically. Custody should be awarded to the parent who is best able to provide for the children’s welfare. In some cases, children experience severe stress when living or spending time with a parent. Many fathers have demonstrated both their competence and their commitment to care for their children (Fig. 27-4).

Often overlooked are the changes that may occur in the children’s relationships with other relatives, especially grandparents. Grandparents are increasingly involved in the care of young children (Fergusson, Maughan, and Golding, 2008). Grandparents on the noncustodial side are often kept from their grandchildren, whereas those on the custodial side may be overwhelmed by their adult child’s return to the household with grandchildren.

Two other types of custody arrangements are divided custody and joint custody. Divided, or split, custody means that each parent is awarded custody of one or more of the children, thereby separating siblings. For example, sons might live with the father and daughters with the mother.

Joint custody takes one of two forms. In joint physical custody, the parents alternate the physical care and control of the children on an agreed-on basis while maintaining shared parenting responsibilities legally. This custody arrangement works well for families who live close to each other and whose occupations permit an active role in the care and rearing of the children. In joint legal custody, the children reside with one parent but both parents are the children’s legal guardians and both participate in childrearing.

Coparenting offers substantial benefits for the family: children can be close to both parents, and life with each parent can be more normal (as opposed to having a disciplinarian mother and a recreational father). To be successful, parents in these arrangements must be highly committed to provide normal parenting and to separate their marital conflicts from their parenting roles. No matter what type of custody arrangement is awarded, the primary consideration is the welfare of the children.

Single Parenting

An individual may acquire single-parent status as a result of divorce, separation, death of a spouse, or birth or adoption of a child. Although divorce rates have stabilized, the number of single-parent households continues to rise. In 2009, 27.3% of children younger than 18 years lived in single-parent families and the majority of single parents were women (Kreider and Ellis, 2011). Although some women are single parents by choice, most never planned on being single parents and many feel pressure to marry or remarry.

Managing shortages of money, time, and energy is often a concern for single parents. Studies repeatedly confirm the financial difficulties of single-parent families, particularly single mothers. In 2004, only one third of mother-headed households received any child support or alimony (Annie E. Casey Foundation, 2009). In fact, the stigma of poverty may be more keenly felt than the discrimination associated with being a single parent. These families are often forced by their financial status to live in communities with inadequate housing and personal safety concerns. Single parents often feel guilty about the time spent away from their children. Divorced mothers from marriages in which the father assumed the role of breadwinner and the mother the household maintenance and parenting roles have considerable difficulty adjusting to their new role of breadwinner. Many single parents have trouble arranging for adequate child care, particularly for a sick child.

Being a teenage parent adds to the financial burden of being a single parent and can have long-term consequences for the mother and child. Poverty is a well-known predictor of adverse effects on a child’s health and well-being. Approximately 78% of children born to a teenage mother who did not marry or graduate high school live in poverty. In contrast, only 9% of children born to women older than 20 years who marry and finish high school live in poverty (Annie E. Casey Foundation, 2009).

Social supports and community resources needed by single-parent families include:

Single parents need social contacts separate from their children for their own emotional growth and that of their children. Parents Without Partners, Inc.* is an organization designed to meet the needs of single parents.

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Sep 16, 2016 | Posted by in NURSING | Comments Off on Family, Social, Cultural, and Religious Influences on Child Health Promotion

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